Wednesday, March 10, 2010

Being Threatened

How many of you have a job where you could, at times, be physically or verbally abused? And threatened? And pushed beyond your limits of self-dignity?

Welcome to the ER.

Anyone who has ever worked in an emergency department or a trauma center has a story to tell about being threatened. It's not a good feeling and, in fact, is something that one can carry with them long after the event, dwelling on their minds and weighing down their hearts. We all, I think, have a little part of our self-worth damaged at times like that. And even though you did nothing wrong, you still ask yourself repeatedly "What did I do to deserve this?" or "Could I have done something different?" Nine times out of ten, that answer would be "no." But that crazy thing called guilt can flip the coin and make you feel like you were responsible.

For example, when an alcoholic or druggie comes in and threatens to "beat the shit out of you" or "find out where you live and come carve you up," it's par-for-the-course, something we have all been trained to deal with. We are asked to look beyond the abuse and realize that it's "not the patient talking" but, rather, the drugs and alcohol. Yeah, okay. For the most part, I can buy that. But we all have limits, and it takes tremendous professionalism and restraint to continue treating that patient. And of course, we always do.

Likewise, if a psychiatric patient presents during a crisis, a break from reality, they may lose the ability to discern between what is normal, accepted behavior and what is harmful, threatening behavior. And again, the ER staff is usually on the receiving end of their irrational actions or words. Recently, a schizophrenic patient sprayed us with her saliva while glaring at us with her distant, disconnected eyes, spatting away and trying to bite or hit anyone near her. Even after a face-mask was placed, she still managed to hurl some extremely hurtful, vulgar comments at our staff, particularly at a medical student who had some acne issues and a female guard who was not a size 8. One of our nurses ended up with a bruise.

Hell, about ten years ago, I even had a psychiatric patient tell me that he was going to find out where I lived and "take you out." I hadn't been the first doctor and I'm sure I wasn't the last that he threatened but, trust me, you don't sleep well after something like that.

We accept these words and these blows, these mean-spirited, personal insults delivered with flailing arms and legs, because we signed-up for our jobs in the ER. But, we are still human, and there are days when this type of threatening or abusive patient is harder to accept and deal with.

The hardest part, though, isn't the expected threats, such as from the above patients. Rather, it's the unexpected threats from the sane-appearing patient who decides to take out all of his frustrations on the ER staff. For this reason, I rarely let a patient get between me and the treatment-room doorway.

A while back, I signed on to treat a twentyish male who had waited for about two hours for a complaint of one week of cough and cold symptoms, exacerbating his asthma. He continued to smoke despite feeling that his symptoms were getting worse, per the nursing triage note.

As I walked down our brightly-lit corridor, towards his room, I exhaled a deep, thankful breath, happy to have my last patient survive her stroke. Unknowingly, though, I was walking towards a room of rage.

I pushed the curtain to the side and walked into the room, all while extending my hand to introduce myself. Lying on a cot in the dimly-lit treatment room, watching the small TV in the upper corner, was a young man who looked very pissed-off. He may have weighed 130 lbs. wet, 5'7" or so. After I entered, he shifted his glaring eyes onto me.

"Hello," I started, "I'm Doc..." Unfortunately, I didn't get to finish. In a flash, this patient had jumped off his cot and towards me, his arm cocked-back and his fist balled. He stopped a few feet in front of me.

"I had to wait almost three hours for you to get your ass in here. Can't you see I can't breathe?" He yelled in full sentences, no distress evident. By triage notes, he was stable and had had an excellent oxygen reading. There was no mention of this patient being unreasonable, although I later learned that security had to approach him in the waiting room to calm down. He continued. "You motherf...ers are treating everybody but me."

Yes, my heart was racing. And yes, I was completely caught off-guard. We had a brief moment of silence where our eyes locked, and I could see his extreme rage.

"Put your fist down," I said firmly, holding my ground, shifting my eyes to his cocked-arm. "If you touch me, I promise you that you'll be covered with cops and security before you can blink." Instinctively, while speaking, I raised both of my hands, preparing to catch or block a thrown-fist. Why didn't I retreat? I'm not sure, exactly. Although I had about 70 pounds and six inches on this patient, that would mean nothing if this guy had a gun or knife. But frankly, during a moment like this, it's hard to fully grasp all that is happening.

The patient continued to keep his arm cocked as he ranted. "Motherf...ckers, sons-of bitches, assholes," he yelled, "making me God-damn wait like this. I want some God-damn treatment and I want it now." Finally, after his rant, he took a step back towards his cot.

By now, because of the commotion, I knew that security would be rushing to the room. And they did, but not before one of our techs, a 350 lb. brute, came in first to back me up. Security soon followed and, after we offered some very brash options of either being arrested (if he continued his behavior) or cooperating or leaving on his own accord, the patient requested to be treated. Since I'm not easily intimidated and wasn't sure how ill he was, I agreed to treat him, but not until after I spelled out in exact terms how we expected him to behave. He hesitantly agreed to our terms.

Under watchful eyes, I obtained a history from this patient and performed a thorough exam. I tried my best to maintain my professionalism and act as if this patient hadn't wanted to jump me mere minutes before. Fortunately, I found him to be just as the triage nurse had noted. He had been appropriately placed behind our more critical patients for treatment.

The respiratory therapist came down, soon after, to give this patient a breathing treatment. Before she entered the room, I explained to her why security would be sitting outside of his room in the hallway. We both walked to the room together, only to find no security sitting outside.

"Go back to the station," I said, "I'm not sure what happened."

Well, as it turns out, this patient, following another angry outburst aimed at our security, had decided to leave without any further treatment. And wouldn't you know, the next day he returned. I wasn't even aware he was back until I heard a big ruckus. Again, a lot of verbal abuse towards one of the ER nurses and one of my partners. Our security was ready, though, and the police were notified.

Although we'll never know for certain, there did not appear to be any alcohol or drugs involved. No psychiatric history, either. He simply was a very disgruntled, angry man who wanted his medical treatment immediately, for symptoms that had been present for almost a week. In order to jump the line of waiting cardiac, stroke, and trauma patients, he had been willing to risk threatening several of us.

At times, we can face some real dangers with our ER jobs. My hat is off to all of my fellow ER comrades, from the secretaries to the techs, from the nurses to the docs, and from the security to the police. I salute your continued resilience and professionalism, especially during these abusive moments.

As always, big thanks for reading. The next post will be Friday, March 12. Until then...


Winking Doll said...

Paediatric nursing is another area where one gets threatened, spitted and shouted at, hit, etc. Thankfully, most times the parents are embarrassed about their child's behaviour. Nevertheless, there are unreasonable doting over-protective parents/grandparents/caregivers who blame the staff or blindly accuse them! Thank goodness they are not norm.

Anonymous said...

Just found your blog and am enjoying it immensely.

Perhaps when we stop with the "customer service" crap for these violent abusers and start with criminal prosecution, this behavior would slow down. We can usually tell a psychotic break or chemical problem from the entitled bullies, and the latter need a stay at the GrayBar hotel, not the hospital.

And slightly on a tangent---why oh why do administrators send P-G surveys to Medicaid patients, or those who are frequent fliers and drug seekers, or jackasses like your patient in this post?? Why should we CARE if these folks don't like our "culture of caring?" Hospitals in general but the ER in particular are for the urgently sick.....and when I hear a malingering idiot say that they will NOT come back, that is great and NOT a threat at all!

PAttie, RN

Tanya said...

My hat is off to you for being able to maintain your professionalism while dealing with abusive patients. I took an early retirement from my job partly because I could no longer handle the verbal abuse I took on a regular basis from customers.

Marcy Hall said...

sounds a lot like the public library!! but then, you know that. :) scary!

Heather said...

It's awful, really.

Patients so easily forget that they are not the only patient in the hospital...or as I like to often remind them... "This is a hospital not the Hilton---that's what that big red H stands for!"

Anonymous said...

Unfortunately this kind of verbal abuse and physical threats isn't just limited to trauma rooms. I've worked on a mental health outreach team as a recreation therapist, where I've been punched in the face by a female client and sexually harrased by another. I've also worked in a rehab hospital where I've dealt with my share of violent, angry, threatening patients and family.

Katie said...

I'm sorry that's something you have to deal with.
<>< Katie

Stephany said...

Being in the psych world as much as I am as an advocate for my daughter, I have seen it all and heard it all. Always remember the hurtful words are just words and the people are just not a good representative of who they are at that moment. This is why I would take in photos of my daughter to meetings, so they could see that.

Best way to deal with it is to continue to treat them with dignity, and respect and compassion with a calm and even-toned voice. Though not in a good space in their mind at the moment, they are people(human beings) and do hear you, when a person may not think they do.

I have seen ER staff leave my daughter locked in seclusion in urinated clothing, and I have seen ER staff treat her with compassion and bring her blankets and scones with a smile.

Remember, sometimes the prescribed medications can agitate patients as well as increase psychosis, always consider it can be more than street drugs that create that behavior.

I have stood by and watched my daughter be strapped to gurneys and spit shield placed on....heart breaking times for a mom, where the compassionate way people treat my daughter is always appreciated!

Winking Doll said...

To PAttie, RN at March 10, 2010 7:23 AM:
when I hear a malingering idiot say that they will NOT come back, that is great and NOT a threat at all!

Unfortunately such cases often come back AGAIN! In paeds, sometimes it is their caregivers who are abusive.

Cal said...

It takes a lot to carry on caring for someone after suffering their threats and abuse. I am not sure I could do that. In fact I am pretty certain I would not, so my hat goes off to your guys who do this on a daily basis.

Smalltown RN said...

Doc I feel your frustration. I have worked in ER, ICU and now Recovery room. Like you I have been spat at, punched, kicked, scratched, sworn at and the list goes on. Was the cause of these behaviours drug or ETOH induced, was is it a pychiatric event, who knows, it just happens. Our security is a joke. By the time they arrive it's often to late,usually the nurses have managed to restrain the patient or the patient has left the building. I can remember one time in particular when this patient became agressive and started kicking and swearing, there were male doctors in the area...not one of them came to our assistance, by the time security arrived we had the patient back in bed restrained physically and chemically. It's frustrating to say the least. But it's an evironment where the only thing for certain is the uncertainty of any situation and knowing to be prepared for it.

Another great post Doc....thanks!

Leslie said...

At my job we also deal with being assaulted. Unfortunately we don't have a security team, we have to restraint the "customers" ourselves. It goes without saying that we are also verbally assaulted, I can't count how many times I have been called f'en b*tch. We get insults and threats too, though the threats are less common than the actual assaults.

What do I do? I work with foster kids ages 7-18 that have behavioral issues. When a 7 yr old hits you and calls you a f'en b*tch it does mess with your brain. The teenagers are, of course, more scary when they become assaltive...but you know how it is, all in a day's work.

Maggie said...

My thoughts are with you when have to deal with abusive patients. I have worked in the mental health field and know what it is like, receiving abuse from both adults and children. While I rarely use an ER I have had the reverse experience. In addition to my working in MH, I also experience incidents of major depression. Once my doctor suggested I go to the ER of a major mid Atlantic teaching facility to be admitted. The hospital had a separate locked pysch emergency room and I was escorted in there and left to wait. A history was taken and then I got to wait some more. My husband was in the waiting room and was never given any updates. After about four hours, a woman came in and told me my insurance would not approve my admission so there was nothing they could do. New face, no introduction...I asked who she was..."I am the doctor on duty" Perhaps it would have been nice to introduce yourself to me. At this point of waiting, along with the frustration of being jerked around by my insurance company for a week, I lost it. Yes I was hysterical. No I was not abusive. The nurse who came and screamed at me from the hallway that I "HAD TO CALM DOWN' was abusive. A security guard came in to the room and spoke calmly to me until they brought me a shot to calm me down. I will never forget the kindness of the security guard, nor will I ever forget the inappropriate screaming of the nurse. Needless to say, despite the hospital's reputation of being "the best", I will never return.

terri c said...

Even as a hospice chaplain I have gotten the verbal treatment from some family members. Sadly, there are folks who have only one tool, that being nastiness, to cope with any of life's difficulties. However, if I can come to your ED and lie on a nice cot with warm blankets and TV for 3 hours I will thank you for the break!

Leslie said...

@ Maggie...I am so sorry you that awful experience. You should not have been treated so unkindly when you were clearly not in a "good space". I'm grateful that at least the security guard showed some compassion.

Jabulani said...

Having spent more than my fair share of time in an ER room, I've discovered that being abusive with a non-threatening condition is only likely to get you bumped. On the other hand good manners and politeness generally gets you far and fast. So when my children require Casualty services, I opt for the latter even if it is 1am and I've not long been in bed!! Oh yes, and I try to avoid Friday and Saturday nights which seem to be the times the dross of humanity feel it appropriate to frequent an ER waiting room spewing forth not only the contents of their stomachs but their vitriole at excessive volume too.

t. said...

Thanks for what you (and many others like you) do, Doc. A dear friend of mine is an ER doc and never wants for stories that would make the faint of heart gasp, blanche, and run for cover; she still goes back, like you, shift after shift, to be the front line in caring for those that need it, even when they may not "deserve" it. So indeed and truly, Thank you!

belladawn said...

Oh...the abuse that we medical professionals take. I try to see it from their perspective. They are sick and scared. Does that excuse the treatment? NO. It does help keep me calm. I usually try to go with the therapeutic approach. I usually get along after a few minutes with these people. I work along the lines of law of attraction. If they are frustrated and scared, I try to deflect it with kind and understanding. They end up opening up to me and listening a whole lot better. It may not stop the asthmatic from smoking but I feel if I can get them to open up maybe someday that small inkling of care will help that flower blossom.

We are taught not to tell our patients that we are overworked and understaffed. Why? The hospital doesn't want to look bad. At this point, I don't care. The hospitals don't want to hire more people? Well, so be it. The truth is the truth. Hire more people. It is the same everywhere. If we hire more staff, he wouldn't have to have waited so long and he wouldn't be upset. Sorry, I know we all want to place the blame but I believe we should start at the top. Do we need ALL those big wigs at the top getting paid ALL that money? They implement changes that rarely work. It isn't just the hospitals. You can see it all over. Schools, government...the list goes on and on. The big wig sit in their plush little offices going to catered meetings all day while the staff barely have a chance to eat half the time. They don't have to put up with the abuse. They don't really care. The one's of us who do are left to treat the battered and scared and become battered and scared.

We all feel helpless against the people who make all the money because they don't listen. VICTIM MENTALITY! We need to make them listen. Maybe if you took a comment card for them to fill out when they are mad and helped each and everyone of them with filling it out...the picture would start to become clearer. You write to release...give them a chance to do the same. ;) Of course, then you would be in trouble for inciting a riot among the peasants. Then we get out of the victim mentality and into fear of losing our jobs for fighting for the rights of others. It is a vicious circle. Go Norma Rae.

Peace and love to you!

Anonymous said...

So, do you think angry young man got his breathing treatment at the local jail?

Anonymous said...

In Toronto (Canada)— not sure about other Cities and Provinces— a patient who is experiencing a mental health crisis is labelled as soon as they arrive at the charge desk. If they are brought in by Police (for calling 9-1-1, or a crisis line) they risk obtaining additional labels including a Form 1, which requires them to be seen and held in hospital for a minimum of 72 hours and then re-assessed. The Police also give the label, "EDP" when writing their reports on patients in an ER and have to stay with the patients in their room until the Physician makes a decision to give the patient a Psychiatric evaluation or to discharge the patient. EDP means, "Emotionally-Disturbed Person."

My friend has been a cop for 3 years and once told me that he had a long shift waiting around the hospital with an EDP again and what a drag it was.

What I find more compelling than all of this complaining about patients with Mental Health concerns is how they can be better served in an emergency department versus labelled and packaged away into a crisis unit or "grey bar hotel" as cited earlier by a reader.

The truth is, anyone could potentially experience a "break" at any time in your life, and would you want these labels?

In the moment of crisis, I can understand that a threat or any violence is not tolerable by staff of an ER, but how can this be less-polarized to allow for a more balanced de-escalation of the threat, versus using authoritarian force such as police or security or medication?

Bongi said...

reminds me of the time gang members came to casualties to finish off their business. they plugged their victim quite enough, but for good measure sprayed a bit of lead about. one nurse was hit.

on the positive side, if you absolutely insist on getting shot, i suppose casualties is a pretty good place to do it.

She Who Must Be Obeyed said...

I'm the healthy daughter of one schizophrenic and one alcoholic, and I feel so much gratitude to you and all the other healers who've moved beyond their completely reasonable distaste and reactivity toward my family's behavior to offer them humane, compassionate care. My family is tough to deal with, but they're human, and little moments of kindness actually do seem to help them behave better in the future. The fact that you steeled yourself and helped this man as best you could might have made it easier on his child at home, or his parents or wife. Good work.

Dr. Mongo Lloyd said...

I'm waiting for markps2 to make an appearance, explaining that mental illness is just a social construct and that you probably had it coming for angering the patient.

Earl Grey said...

2 points for Dr. Lloyd.

Seriously, even though you are a healer, you must be entitled to defend yourself if push comes to shove and security (or a 350lb tech) don't arrive on the scene in time.
While it probably goes against all your training and probably sounds pretty tacky, have you ever had to kick a patient's ass?

Jabulani said...

Earl Grey: I read a blog post last week that contained this line:
"Your right to swing your fist ends at the tip of my nose."
I found it an interesting idea; we are all entitled to swing our fists, but we are not all entitled to swing with the intent of connecting with someone. Mental illness or no.

Anonymous said...

ok imagine one of those patients that have waited for 3 to 6 hours, assessed and given a presciption. Now they come to my pharmacy and are told its going to be half hour to an hour wait. They are even more unhappy and sometimes scary. We are expected to smile and be polite though.

Mark p.s.2 said...

75% of family doctors abused by patients: study
"Researchers randomly selected 3,802 family physicians to survey by mail between November 2008 and April 2009. Of the 774 who responded, 98 per cent said they had experienced at least one incident of "minor" abuse, and 75 per cent reported "major" abuse during their career, including being sexually harassed or physically threatened by a patient."
MORE at link

Peter said...

Hi! On the most part, the abuse I and others got when working in ED was the end result of patients having to wait for hours on end to get through the front door of ED.

Did the abuse come from the patients? No, it came from family members who mostly stood around shaking their heads and turning up their eyes for all to see.

Then it was "contain and negotiate" in an attempt to put things right!

Take Care,

Anonymous said...

I'm sure he paid you and your department for your cash, no less :)

SeaSpray said...


I'm sorry, as i am usually more sensitive toward people looking for the deeper meaning for their behavior ..but anyone behaving that way without good reason is an idiot.

I've seen those types come in so often. They are clueless and/or don't care if the pt is stroking out in room 3, etc. Low emotional IQ and intelligence ..or rage problem.

It was amusing when they threatened to leave and did to go to the busier hospital a half hour away and the staff would come out for them just after they left.

The risk of violence is high in the ED. Even by a normal person who could have an intense grief reaction over the loss of a loved one.

I wish people could be forced to watch a replay of their behavior before they are discharged.

I was a little nervous about our temporary (years) set up until new ED was remodeled on another floor. the reception desk was situated right by the ED entrance. It was the first room patients entered before going to triage. There were cameras, but you're too busy working and they weren't set up well for our viewing. Working at least until 11 and longer ..i did not like that if behind the registration desk ..there was no other exit. And so a potentially violent person would be between registration person and the hallway or exit. The nurse's station was down the hall.

Sabra said...

Try being an ER doctor over in Saudi! A friend of ours, a physician from Canada, was here in Saudi working and in the middle of the night a man brought his wife to the hospital because she couldn't breathe. The wife, as is custom, here, was covered in head-to-toe black. Jim - ER doctor - had his stethoscope in hand and went to press it on the woman's chest to "hear" the problem and ended up with a black eye and a bloody nose because the husband could not handle that he touched the woman's chest with his stethoscope. Charges were filed, the man was escorted out by security and taken to jail. The wife had to get a taxi home since women are not allowed to drive here. Jim no longer works in Saudi and has gone back to Canada. Even though the money was great, here, for him, he decided that the actual abuse just wasn't worth it. He was physically assaulted more than once by angry husbands who don't understand that you cannot treat a patient without examining the patient.